Causes and management of sight threatening complications of dermal filler injections: A review.

Injectable dermal fillers continue to increase in popularity in aesthetic medicine. Although rare, vision loss secondary to filler injections is a devastating complication associated with a poor visual prognosis. The mechanism for vision loss is thought to be related to retrograde embolization of the dermal filler from peripheral vessels in the face into the ophthalmic arterial system. Early recognition and prompt management are essential if vision is to be salvaged. The use of retrobulbar hyaluronidase is still contentious, however when administered by a specialist, this treatment gives the best chance at visual recovery and should be considered for all cases.

Early low-dose rituximab for active thyroid eye disease: An effective and well-tolerated treatment.

BACKGROUND: Thyroid eye disease (TED) is an autoimmune inflammatory disease that can be disfiguring and potentially sight threatening. Suppression of inflammation in active disease can reduce the risk of visual loss and limit long-term sequelae. Current management involves inflammation suppression using glucocorticoids. The aim of this study was to evaluate the efficacy of early disease intervention with targeted immunomodulatory therapy to alter disease course. This paper reports the efficacy of low-dose rituximab in reducing clinical activity in TED in a small population. METHODS: A retrospective audit of consecutive patients with active TED managed primarily with a 100 mg rituximab infusion. Further glucocorticoid or steroid-sparing agents were prescribed if clinically indicated. Clinical activity score, VISA overall severity score and Oxford Quality of Life score were recorded at each visit as well as TSH receptor antibody levels (TRAb), B cell subsets and adverse reactions. RESULTS: Twelve patients had mean follow-up of 6.3 months. Clinical activity scores significantly decreased (mean score 5.08 to 1.58; P < 0.001), VISA overall severity scores reduced by 50% from 12 to 6, P < 0.001 and the mean cumulative dose of IV methylprednisolone was 2.3 g. 100 mg rituximab induced significant CD19+ B cell depletion (n = 8, P < 0.001). There was no significant reduction in serum TRAb (n = 8, P = 0.06). A transient infusion-related rash was the only adverse effect, n = 4. QoL scores did not differ markedly before and after treatment. CONCLUSION: Low-dose rituximab is an efficacious, well-tolerated and safe treatment for active TED; reducing disease activity and allowing reduced administration of systemic steroid.

Early use of steroid-sparing agents in the inactivation of moderate-to-severe active thyroid eye disease: a step-down approach.

OBJECTIVES: The current first-line treatment for management of active thyroid eye disease (TED) is high-dose intravenous corticosteroids, which have the potential for serious adverse effects. Our aim was to evaluate the effect of steroid-sparing agents (SSAs) in patients with moderate-to-severe active TED, using methotrexate as first-line. METHODS: Presented is a retrospective, four-year, single-centre, consecutive case series of patients with moderate-to-severe TED treated using the Oxford protocol. Treatment modality, disease activity, and adverse effects are reported at presentation, 6- and 12-month follow-up. RESULTS: 104 consecutive TED patients treated by the Oxford TED team were reviewed. 24 patients with moderate-to-severe active disease were identified (mean age 46.8 years;12 female) with a mean pretreatment VISA inflammatory index score of 5.5/10 (SD = 1.98; range 1-9). Intravenous methyl-prednisolone (IVMP) and an SSA was commenced in all patients. Mean total steroid dose was 2.72 g (SD = 1.4;1.0-6.9). 38% of patients (n = 9) received ≤1.5 g of IVMP. Only two patients required >4.5 g of IVMP equating to the EUGOGO treatment protocol dose for this patient group. There was significant improvement in inflammatory index score both at the intermediate review (mean score 2.7; SD = 2.8; P < 0.001; mean follow up 25.2 weeks) and at one year or last follow-up (mean score 1.4; SD = 1.5; P < 0.001; mean follow up 48.0 weeks). No serious or long-term adverse effects were reported. CONCLUSION: This study suggests that the initiation of an SSA, using methotrexate as first-line, with limited adjuvant IVMP is an effective and safe treatment for moderate-to-severely active TED, resulting in a significant reduction in both disease activity and total steroid load.

The "reading man" flap for reconstruction of large periorbital defects.

PURPOSE: The "reading man" flap (RMF), a double advancement transposition cutaneous flap named for its appearance, has been described in the reconstruction of various circular skin defects, particularly in the malar region. We describe two cases where this flap was used to reconstruct the lower eyelid/periorbital region. METHODS: Two oculoplastic patients with lower eyelid basal cell carcinomas underwent Mohs micrographic excision resulting in a large skin defects. In both cases, reconstruction was performed using the RMF. RESULTS: At 6 months, both patients achieved good cosmetic results with no case of secondary eyelid malposition. CONCLUSION: The RMF is a useful adjunct to the armamentarium of the oculoplastic surgeon for the reconstruction of large periorbital defects.

Use of x-ray film implant for the repair of orbital fractures.

PURPOSE: To evaluate the experience with sterilized x-ray film in the repair of orbital blow-out fractures (BOFs). METHODS: A retrospective review of case notes from 56 patients with orbital BOF repaired using sterilized x-ray film onlay implants at 2 institutions between November 2004 and December 2010. Patient demographics, timing of surgery, surgical approach, postoperative complications, and length of follow up were recorded. RESULTS: Fifty-six patients (44 men, 12 women) received sterilized x-ray film implants during the 6-year study period. Mean age at the time of repair was 29 years (range 4-85 years). For 68% of patients, surgical repair was performed within 2 weeks of injury. Average length of postoperative follow up was 5.5 months (range 1-36 months), 48% had follow up >3 months. Following surgical repair, diplopia in primary or down gaze reduced from 98% to 4% and enophthalmos ≥2 mm reduced from 21% to 5% cases. One patient required a second operation for repositioning of an incompletely reduced fracture. A second patient presented 9 months postoperatively with recurrent episodes of proptosis, and the implant and its surrounding pseudocapsule were subsequently removed. There were no cases of visual loss, implant infection, or migration. CONCLUSIONS: This series has demonstrated that in selected orbital fractures sterilized x-ray film can provide a safe, effective, and low-cost onlay implant.

Optic disc area and correlation with central corneal thickness, corneal hysteresis and ocular pulse amplitude in glaucoma patients and controls.

BACKGROUND: To examine the relationships between optic disc area and parameters measured at the cornea; central corneal thickness (CCT), corneal hysteresis (CH) and ocular pulse amplitude (OPA) in glaucoma subjects and controls. METHODS: In this prospective experimental study, patients underwent measurement of CCT, OPA, CH and optic disc imaging with the Heidelberg Retina Tomograph II (HRT-II). Pearson's correlation coefficient was calculated to assess the associations between optic disc area and CCT, OPA and CH. RESULTS: A total of 100 patients, 38 with glaucoma and 62 controls were examined. In a univariate analysis of this group, CCT and CH were significantly lower in glaucoma patients (P = 0.01). CCT was inversely correlated with optic disc surface area (Pearson's correlation coefficient r = -0.200; P = 0.05). This inverse correlation did not achieve statistical significance when glaucoma patients and controls were analysed separately. There was no statistically significant association between optic disc area and OPA or CH. CONCLUSIONS: There was an inverse relationship between CCT and optic disc area in this study group. No association was found between optic disc area and OPA or CH.

Risk factors for first presentation of glaucoma with significant visual field loss.

PURPOSE: To identify risk factors associated with visual field (VF) loss on first presentation of glaucoma. METHODS: A case-control study of 107 consecutive newly diagnosed glaucoma patients was performed. Information collected included demographic data, reasons for referral, ophthalmological assessment and VF testing. VF grading was based on Advanced Glaucoma Intervention Study (AGIS) scoring and was additionally classified for the presence of a nasal step, paracentral scotoma and/or arcuate scotoma. RESULTS: Demographic parameters were: mean age 59 years (standard deviation [SD] 14), mean deviation -4.37 dB (SD 4.5), intraocular pressure 21.4 mmHg (SD 6.6) and cup:disc ratio 0.69 (SD 0.1). Thirty-seven per cent of all participants had a positive family history of glaucoma. Older age was associated with a VF defect at presentation (mean age of 54 years with no VF defect, compared with 63 years for mild, moderate or severe VF defect, P = 0.0014). Multivariate logistic regression analysis identified positive family history (odds ratio [OR] 10.43; 95% confidence interval [CI] 1.67-67.49) and age (OR 1.15; 95% CI 1.06-1.26) as independent risk factors for VF loss at presentation. Fifty-six per cent had a paracentral VF defect at first diagnosis and 29% of patients showed evidence of substantial VF loss with AGIS score of >/=6 on initial presentation. CONCLUSIONS: Patients who have a positive family history of glaucoma are 10 times more likely to have a VF defect at the time of glaucoma diagnosis. An increased focus on family history may help identify these patients earlier and prevent significant visual loss at the time of presentation.

Visual field changes after transient elevation of intraocular pressure in eyes with and without glaucoma.

PURPOSE: To evaluate visual field (VF) changes in glaucomatous and nonglaucomatous eyes after transient elevation of intraocular pressure (IOP). DESIGN: Prospective experimental study. PARTICIPANTS: One hundred subjects (38 with glaucoma, 62 glaucoma suspects and controls). METHODS: Intraocular pressure elevation was induced in the right eye of all subjects with a modified LASIK suction ring. Intraocular pressure was elevated to an average of 64 mmHg for <30 seconds. Humphrey Matrix perimetry 24-2 threshold tests were performed before and after the procedure. A cohort of patients who demonstrated significant deterioration in postprocedural perimetry was recalled for further testing. MAIN OUTCOME MEASURES: Mean deviation (MD) and pattern standard deviation (PSD) from Humphrey Matrix perimetry. RESULTS: A significant decline in MD of the right eye could be observed on immediate postprocedural perimetry amongst glaucoma and control patients, whereas no significant changes in PSD were seen in either group. Forty-five of 47 patients, whose immediate postprocedural perimetry showed a loss of MD > 2 decibels, attended for repeat perimetric testing with a median follow-up of 6 days. Both eyes among 28 control patients and the left eye among 17 glaucoma patients showed statistically significant improvement in MD. Similar improvement was seen in the right eye of glaucoma patients, but this failed to reach statistical significance. Six patients from the glaucoma group demonstrated deterioration in MD upon recall, compared with 3 in the control group (P = 0.046). These 6 patients were significantly younger than the rest of the group, but no other defining characteristics were identified. CONCLUSIONS: Transient elevation of IOP in adult eyes with and without glaucomatous optic neuropathy did not lead to functional optic nerve change, as measured by Matrix perimetry, in the short term for the majority of patients. It is possible that a small cohort of patients with preexisting glaucomatous optic neuropathy may be more susceptible to transient increase in IOP, although the result is inconclusive. Prominent learning effects may have masked subtle worsening of visual function in our subjects; corresponding structural analyses of the optic nerve and longer-term follow-up may provide further information.

Observed smoking in cars: a method and differences by socioeconomic area.

OBJECTIVES: To establish a reproducible method to estimate he point prevalence of smoking and second-hand smoke (SHS) exposure in cars, and to compare this prevalence between two areas of contrasting socioeconomic status. METHOD: A method involving two teams of observers was developed and evaluated. It involved observing 16,055 cars in Wellington, New Zealand. Two of the observation sites represented a high and a low area of deprivation (based on a neighbourhood deprivation index) and three were in the central city. RESULTS: A 4.1% point prevalence of smoking in cars was observed (95% confidence interval (CI) 3.8% to 4.4%). There was a higher prevalence of smoking in cars in the high deprivation area relative to the other sites, and particularly compared to the low deprivation area (rate ratio relative to the latter 3.2, 95% CI 2.6 to 4.0). Of cars with smoking, 23.7% had other occupants being exposed to SHS. Cars with smoking and other occupants were significantly more likely to have a window open (especially if the smoker was not the driver). The observation method developed was practical, and inter-observer agreement was high (kappa value for the "smoking seen in car" category 0.95). CONCLUSIONS: Observational studies can be an effective way of investigating smoking in cars. The data from this survey suggest that smoking in cars occurs at a higher rate in relatively deprived populations and hence may contribute to health inequalities. Fortunately, there are a number of policy options for reducing SHS exposure in cars including mass media campaigns and laws for smoke-free cars.